CMS Mandated Changes for Unannounced Surveys
Have you heard the news?
Starting July 14th:
No more notification of surveys. Accrediting organizations will no longer be able to post the morning notifications on the day of the survey. The notification will be given when surveyors physically walk on-site.
Six months before the survey cycle, we may see changes with the electronic application for accreditation (eAPP) or other ways the Joint Commission (TJC) communicates with us related to survey team size, facility info, etc.
No more “black-out” dates. You’re probably wondering, why? Well, CMS feels this practice is also inconsistent with the policies of unannounced surveys and the expectation that a provider must always be “survey-ready” at all times. If there are key individuals out there needs to be plans for redundancy on who can step in at any time.
No more complaint communications by correspondence. Accrediting organizations will either have to come on-site if they believe the complaint is an Immediate Jeopardy or condition-level finding or they can roll into the next accreditation survey if it is a lower-level complaint.
Findings will become public records. TJC detailed reports typically have not been posted except for the accreditation status of organizations. At this point, it is unsure if they will mimic something like the California Department of Public Health (CDPH) where the public can see all survey activity and reports, or if it will be an on-demand request process.
When it comes to healthcare organizations, unannounced surveys by the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) can strike fear into the hearts of administrators and staff. However, these surveys are an important part of ensuring that healthcare facilities are providing safe and effective care to their patients.
The Joint Commission is an independent organization that accredits and certifies hospitals and other healthcare organizations. They conduct unannounced surveys to evaluate a facility's compliance with its standards of care. The CMS, on the other hand, is a federal agency that oversees Medicare and Medicaid programs. They also conduct unannounced surveys of healthcare facilities to ensure that they are meeting the conditions of participation in these programs.
One of the key reasons for conducting unannounced surveys is to get a true picture of the day-to-day operations of a healthcare facility. When staff are aware that a survey is coming, they may go out of their way to ensure that everything is in compliance, but this does not necessarily reflect the reality of the facility's operations. Unannounced surveys help to identify any gaps in care that may not be immediately apparent during a planned survey.
Healthcare organizations need to be prepared for unannounced surveys at all times. This means maintaining compliance with regulations and standards on an ongoing basis, rather than just in the lead-up to a survey. Staff should be trained on the requirements for compliance and should be aware of their roles and responsibilities in maintaining a safe and effective care environment.
During an unannounced survey, the Joint Commission or CMS will typically evaluate the facility's compliance with a wide range of standards, including infection control, medication management, patient rights, and more. They may also conduct interviews with staff and patients to get a better sense of how the facility operates on a day-to-day basis.
While unannounced surveys can be challenging for healthcare facilities, they serve an important purpose in ensuring that patients receive safe and effective care. By maintaining compliance with regulations and standards at all times, healthcare organizations can be better prepared for these surveys and can ensure that they are providing the highest level of care to their patients.
